GW1-2021-07858_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD F`orFnk-nml fv&0N-UK
This:form can tv umd rorsiugle or mW[ip)c wells
1.Well Cantractoritrlornjation:
1d.'MATE7t+ION FS
John Eisenman IrRo11 I 'f[t McklI ION
N`0AtCorftm t Kam.
4439A
NC Well Comractor Certiftcatiao Ntunbea 15.OUT.ER CASiNG-Vifr_enitikame'it*i tns OR1,1N -R.Mj4"kcal•
FROM I To VAMFTER TFUCKIMRS ATAiERTAL,.
SAEDACCO Inc 0 fc 48 iL 2" 1 in. SCE-40 PVC
CafiVut'Name f8,f Nft GA 17""CIO 77a�JI>YG F P9Af3ii ttiSCd t ,'z_
FROM 10 MCM[ETER, YMCKNESS MATMAL
2,Wrlt rpnom uctinn Pcrniit ", ft ft.
l isr all as n?rrtt lr.Wdlpermitt ll_e'.6atrary.S4YIP,Marlamee,lf4kden e1r.)
iL fL i+t,
3.W41 Ilse(C1KX wd1l vso� 17 SCRt Erl. .
`triter Supply Wells _ -- FROM I TO I niAratr,•rm k:ttrsur T"IMMs LMATRIUM,
DAgikult ral i�Ivittnisipcilll`tfbiic 48 ft 50 ft 2^ In. .010 scH=40 Pvc
OGeothermal(Heating,tCooling Supply) ❑R.esidential Water Supply(singlo) ft ft io:
171"dustfial/Camntercial ❑Sesidential Water,Si Wly(slmmd) 10.OR)UT,
FROM ?O MATERP.AL EKKAC'EMENT AMMOD&MOUNT
❑ltn lien 0 ft. 45 fL Portland Tremmie
Non-Water Supply Well: ft.
❑Mouitopn ❑ltccc}s c
Injection Well: f4 fL
out(cr Acchirge, C7 ioiit dRa�tcr Rc FtedW on 'I9;;ShNti[7 i?ETTACFMUon.tvbte
. - .rR1�Af. :.. r - tA'1`.'kCAt. �9P5�AS►yi7 AjF;Y"H n
MAgpifcr$totagc atrl Rc�ovc ' [pSihnity J3aii cr 47 rr, 50 ft, SAND #2
❑Aquifcr`test ❑$tvmmatubmirac ft. it
❑Expuimental'Tcclmotcgy ❑Snbsidcmc CoMm1
2t�,:T1R71.1.111C'1tJG"(aichti4ifi(iQriet sFreds$f eocceFsan-
OGeothemjal(Closed Loop) ❑Tjneel FROM I To MCRImms, tnbitharon Kara ssluaNrl
❑Gexithemjal eatit 1Caoli!eRelum) MOther(. ainunder#21'Retnaft) 0 ft, 50 fL SANDY CLAY
(L ft. A s a` }t
4.Date Welts)Completed:, 10-7-21 Well]D#AS-s ft. (L �.
Sa.Wc4l l:pr atiain:
tt.
7-Eleven #36069 ' ft.
Fssilif}aOn'acrTla>nssct7il�IDSt salictibls}
ft. it,
2375 Lewisville Clemmons Rd., Clemmons, NC, 27012 it ft a;u 'I e�
P1gSicalriddGcss oly-andZip 2t.RIMAIMS }
Forsyth Bentonite Seal 45 to 47ft
Ccinth' patcct itt,atit7 yfirfnAl ,(PIN)
Sh,tar hidc,Rnd l tingitudc in ftme hninutcs/scciands or 4vcinml itc0Y:cs: 22.Certification:
(Ifx�tl freafty:prc I;itllpsi�dt:gistltpi}.
n: W _ 10/13/2021
6.Is(are)the well(s): oPermanent or oTemporary :s t
M•�rgnii�S+hu/ur,r, r �.r�tr,.��K•,��.xv 1 a:e:KJ:icraxxmrtferl,irr-acx+aM�imrr
ivftV IM NCAG 026 x=az 7 '�4.'kw:fC,OdtTA Well Comomr-rWi Srawferds and t mat a
7.Ls this a xtimir to an tAxfta*wells ❑Ves or KNo ropy ei d4v rmord haa'been prnrlrM ro idr ttml?Cncner,
If rlr is a repMr,.fill our An44n well eorksvn(Moa brjormarlurt aid de plalar die❑arure of fir
repair tinter 921 irma&v smfiaw or•-ai Me bimkof this JFhaL 23.Site drwam or additional well demi[s:
You nia} use1k back'af this page.to proi�da additional well site details or well8.Namber of Hells constructed: 1 constrdetiondetails. You may also attach addilioitat pages if tmcessai'y-
for ottdill de lrrjeerkutor ror+ri-40fee SiTph ireth ONLY w1rh(be same.co"*rction,.yoo ran
xakrnii nur Jarna. SURMITTAL:tik£I EirTIONS
9.Total well dcpih below land frfatG 50 (In.) 2da Fnr All �t"ell4 guhiitit: this f6nn'kidthin 30 dkvs of obinptetion of tistlt
For arrid4p a Kvatla list a lldeptlrr ff-A i rem(e m,•ote-Mzm'and 2@ tm?) constnictvin to the fgil ming,.
10.Static water level below top of casing: (yY,) Division at Water Resources,Information Prneeming Unit,.
1JftblerWei&stiaue rviatrig«am +' 1617 Afar Scn ite Gen c'r.Ralcio,KC 2769)-f617
11.Barebole disinder:8.25" 010 24h.Fnr tnt%flon Wetia ONLY: in addition to sending the form to the address,in
24a above. also submit a copy of this forth within�M days of completion of uvJ1
12.WcU conctt7rGt-au nmthod' 4.2511 HSA c'onsinletion to the folloikving:
(i:e.migcr.iateq•,'cablc.diteri�rsh cle.}
Division of Water ResourcesMaderground ItljOilon Con"I ProgrAm,
FOR WATER SUPPLY WALLS ONLY: I636 Ault 'Service&nter,Raleigh.Nt276"4636
tia Yield(gpm) Method of test 24r For Wager Sn►�gty&lnlertioun WcIls:
Also submit onp capa oP'thts fonm t�tthin;30 days of completion of
]3b.©isJuftc-th n tyli�� Ajnnttnt: wctl constntetion-to the Calmly he lth depa"mrsd of tilt ccnrnty wkm
constructed.
Form GAI-1 N*Nb Camlim Dqann m.,Df Etttiimnnrm and.14n W Resources-Mkion of Waict R1&&rom RcvWd,Aygul2013